Download Neck/Back Pain - Emergency Medicine

CHA P TE R
12
Neck/Back Pain
Amy Gutman
Robert M. Domeier
INTRODUCTION
Back pain is the most common presenting complaint and a major cause of disability in emergency
department (ED) patients.1 These patients have frequent and repeated ED visits, often via EMS, and
often without an obvious physical cause for their
suffering and functional impairment. Neck and
back pain affects EMS patients and providers alike,
and these injuries are among the most common suffered by prehospital providers during routine job
performance.
Spine immobilization is one of the most commonly performed EMS procedures in the management of
the trauma patient. The assessment and treatment of
trauma patients with potential for spine injury and
the concern about spinal cord injury treatment and
prevention are important components of care of the
trauma patient.
This chapter is divided into three sections, occupational back pain among EMS providers, back pain
without acute injury, and back pain following acute
injury. Each section will focus on the specific impact
that neck and back pain has on the provider and on
patients suffering from nontraumatic and traumatic
conditions. Recognition of potentially lethal underlying pathology presenting as neck and back pain are
reviewed, as well as management controversies and
investigational therapies.
THE PREHOSPITAL SYSTEM
AND PROVIDERS
EMS-Specific Statistics
and Impact on EMS
Prehospital providers annually evaluate and transport
over 22 million patients in the United States.2 Back
injury from improper lifting is the number one injury
suffered by prehospital care providers, with an estimated 65% of EMS workers’ compensation claims
resulting from back injuries.3
The overall EMS injury rate is cited as 34.6 per
100 full-time workers per year. “Sprains, strains, and
tears” is the leading category of reported injuries
(36%), with the lower back being the body part most
often injured. Nearly 60% of EMS injuries result in
lost workdays. Back injuries are recurrent in 31% of
personnel, with 25% having more than one injury in
a single year. EMTs suffer a significantly higher injury rate than paramedics. Almost half of paramedics
responding to a survey reported a back injury in the
previous 6 months, although only 39% of these injuries were sustained while performing EMS duties. This
resulted in 13% of personnel requiring time off work,
and over half of those returning to work reporting that
their injury interfered with activities of daily living and
job performance.4
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EMS providers carry and transfer heavy equipment and patients over long distances, often including
flights of stairs. Personnel must have adequate lower
back strength and hamstring flexibility to prevent
musculoskeletal injury while transporting patients.
EMS providers who are overweight or deconditioned
may be at increased risk for back injury due to a lack
of sufficient back strength and flexibility for safe execution of their job.5 Lifting patients causes the majority of back injuries (62%), with most occurring at
the scene rather than at the hospital. There are higher
overall injury rates among women compared with
men and among personnel younger than 30 years of
age as compared with older EMS providers. There has
been no correlation shown between injury rates and
job experience.
Training for EMS Providers
The greatest physical stressors to providers occur while
treating obese patients. The most trying are those requiring extrication from a motor vehicle or tight spaces
(such as stairwells or bathrooms) and outdoor or wilderness rescues over rough and uneven terrain.
Simple interventions can reduce the incidence of
work-related back injuries. These include never lifting
a patient alone and having sufficient personnel available to lift every patient. Chair walkers or wheelchairs
are useful for unsteady patients to decrease the risk
of twisting forces on the provider should the patient
lose balance while ambulating. Slide boards, sheets,
and other transfer devices limit the time any patient is
out of contact with a stable surface, limiting potential
injury to the provider as well as the patient.
THE PATIENT WITH
NONTRAUMATIC NECK
AND BACK PAIN
Statistics
Though the yearly prevalence is stable at 15% to
20%, nearly 80% of adults will experience back pain
at some point during their lifetime, with 31% of patients annually requiring time off from work.6 Male
and female incidence is equal, with an average age
range from 30 to 50 years old. These patients generally share common risk factors of heavy lifting or
twisting, obesity, and poor conditioning.
Resuscitation and Initial Assessment
Airway, Breathing, and Circulation
Airway management is rarely needed in patients with
a chief complaint of neck or back pain. When necessary, successful airway management can be challenged by the very conditions that cause pain. Airway
management in patients with arthritis may by complicated by limited cervical mobility. Patients with rheumatoid arthritis have a greater risk of atlanto-occipital
dissociation with minor trauma, which must be taken
into account when considering using a head-tilt, jawthrust maneuver to open an airway.
Naloxone administration should be considered
in somnolent or unresponsive patients; unintentional
overdoses may occur secondary to the large amounts
of narcotic medications that are often ingested by
patients with chronic pain syndromes, including
chronic neck and/or back pain.
Primary and Secondary Survey
After evaluation and stabilization of life-threatening
abnormalities, the remainder of the patient evaluation
should focus on identifying any additional complaints
or physical findings and an evaluation of the neurologic function of the patient. The provider should focus on changes from the patient’s functional baseline
and presence of any “red flags” indicating illnesses
other than musculoskeletal in nature.
The patient with nontraumatic back pain will
generally not require any type of spinal immobilization, although a rigid backboard may be necessary for
initial transfer to the transporting unit’s stretcher.
General Treatment and Triage Issues
Patients complaining of neck and back pain often have
murky histories and insidious disease processes that do
not provide useful diagnostic clues in the field. Nearly
85% of patients presenting to one major metropolitan
ED with the complaint of neck and back pain were
discharged with a nonspecific diagnosis, often “nonspecific musculoskeletal pain.”7
The assessment should be directed toward identification of life-threatening systemic illnesses producing back pain including myocardial ischemia,
dissecting or leaking aortic aneurysm, and pancreatitis. The single most important examination
finding is evidence of focal transient or persistent
neurologic findings of weakness or loss of sensa-
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tion. Exposure to the patient’s living environment
can give prehospital providers a unique insight into
the patient’s psychosocial issues that may prolong or
amplify the pain.
Risk factors and historical features indicating potentially pathologic underlying causes of
back pain include: age over 50 or under 20 years
old, recent trauma, fever, worse pain at rest or at
night, any history of malignancy or serious medical illness, anticoagulation or immunosuppression, bed rest without relief, duration of pain
greater than 1 month, bowel or bladder incontinence, pain radiating into the leg(s) from the back,
IV drug or steroid usage, or pain increasing with
standing and relieved by sitting. Red flags, or
worrisome signs, include fever of undetermined
origin, unexplained weight loss, radiating pain
with straight leg lift, midline or costo-vertebral
tenderness, pulsatile abdominal mass, or syncope.
Any acute transient or persistent abnormal neurologic examination is considered pathologic.
Chronic low back pain is defined as pain lasting more than 12 weeks, accounting for 50% of total
back pain costs. Overweight individuals appear to
be at the greatest risk, with other factors including
female gender, older age, prior history of back pain,
restricted spinal mobility, pain radiating into a leg,
psychosocial stressors, poor self-rated health, minimal physical activity, smoking, job dissatisfaction,
and widespread pain syndromes, such as chronic
fatigue syndrome or fibromyalgia. Depression, anxiety, mood disorders, and substance abuse occur with
greater frequency among persons with chronic back
or neck pain. Patients with the greatest number of
risk factors appear to have the greatest risk of transitioning from acute low back pain to chronic low
back pain.8,9
Injury-Specific Assessment
and Treatment
Stratified Assessment and Treatment
Unless a life-threatening process is identified, the
majority of patients are appropriately assessed
and managed by BLS-level providers. Emergency
management should be problem focused. Treatment guidelines should include a generalized pain
management protocol with either indirect or direct
medical oversight (DMO). Patients should be transported in positions of comfort and provided psychological support.
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SECTION B
Regional Variations
It is reasonable to transport patients to the facility of
their choice, provided it is appropriate for the management of the identified pathology, with consideration of CT and MRI availability. In patients with
nontraumatic or chronic injuries, there is no benefit in
transportation to a trauma center per se.
Public Health, Social, and Medical
Legal Issues
Social Issues
After an initial injury, most patients will have significant relief of their functional symptoms within 4 to
6 weeks without any specific intervention. However,
during that time, many require repeat ED interventions for which they often use EMS. Repeated EMS
usage places a great burden on the prehospital system
and on the healthcare system in general. Resource use
is highly skewed with 6% of all sufferers accounting
for over 50% of prehospital and ED costs.10
Medical Legal Issues
Prehospital personnel should be wary of potentially serious conditions that might present as neck and back
pain. These conditions include myocardial infarction,
stroke, meningitis, and dissecting or leaking aortic aneurysm, requiring prompt diagnosis and management.
Dismissing symptoms as “uncomplicated” musculoskeletal pain in the elderly or pediatric population, febrile,
hemodynamically unstable, or those without obvious
mechanisms may have a catastrophic outcome.
History should focus on potential acute-on-chronic
conditions, noting changes from prior similar signs and
symptoms, in combination with a systematic physical
examination. Because mechanical back pain is a common complaint, secondary gain may be present for patients both with and without organic disease. It is not
within the prehospital providers’ scope of practice to
refuse care or initiate a treatment refusal because of a
perception that the patient is “faking.”
Documentation of the patient encounter, including a neurologic examination and a nonjudgmental
provider impression of both the physical and psychologic state of the patient, is an important part of
that patient’s record. Documentation should methodically list risk factors as well as demonstrate presence or absence of red flags and reflect the prehospital management based on the history and physical
examination.
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THE PATIENT
WITH TRAUMATIC NECK
AND BACK PAIN
Patients who are determined to be initially without
load-and-go injuries may have a spine injury assessment performed as part of the secondary survey.
Statistics
General Treatment and Triage Issues
A spinal cord injury is defined by a transient or persistent loss of motor or sensory function. There is limited
chance for significant functional recovery if a motor
neurologic deficit persists greater than 24 hours.11,12
There is an annual incidence of 15 to 40 traumatic
spinal cord injuries per million population and approximately 11,000 new spine injuries per year. The
vast majority are secondary to motor vehicle collisions (MVCs; 50%) and falls (20%), with 15% being
secondary to either acts of violence or sports-related
injuries. When considering all causes of sudden traumatic death, 20% are related to spinal cord injuries.13
Spinal cord injury without radiographic abnormalities (SCIWORA) is most common in the pediatric population. There is a reported incidence rate varying from
19% to 34% of all spinal cord injuries in children.14
Spinal immobilization on a rigid backboard is not
innocuous.17 There are significant equipment costs,
patient discomfort, and added cost and time in both
prehospital and ED evaluations. Prolonged immobilization on rigid long boards has been shown to contribute to respiratory compromise,18 decubitus ulceration,
and musculoskeletal pain. The almost universal head
and back pain associated with prolonged immobilization may alter ED presentation and evaluation, necessitating radiographs and prolonged observation that may
have been avoided by omitting spinal immobilization
in asymptomatic patients.19
Selective immobilization protocols result in the
vast majority of patients with spine injury being identified and immobilized, without causing harm in patients
in which spine immobilization was not performed.20,21
The implications for the prehospital system are better
use of resources, decreasing the overall cost of patient
treatment and evaluation. Most protocols are based on
the NEXUS criteria22 or the southeastern Michigan
EMS spine injury assessment protocol.23 The assessment starts with an evaluation for altered mental status
or symptoms that might impede the ability to perform
a reliable examination (i.e., no distracting injury or intoxicating substances). In an alert, reliable patient the
assessment continues with an evaluation for neurologic
deficit and midline spine pain or tenderness. Prehospital
history of any focal neurologic deficit, even if transient,
is absolutely critical to the emergency physician evaluating the patient in the ED.
The decision to perform spinal immobilization
has historically been based on a mechanism of injury
alone. Some hospital-based cervical spine assessment
protocols advocate radiographs for certain “high risk
mechanisms,” taking clinical assessment out of the
equation.24 Despite the demonstrated validity of clinical assessment independent of mechanism of injury,
the prehospital provider should nevertheless rely on
sound clinical judgment in the setting of significant traumatic mechanisms.25 Even without a major
mechanism of trauma, there are particular subsets of
patients at higher risk for spinal injury, including extremes of age and those who have impaired ability to
communicate with the provider. The NAEMSP position paper on spine immobilization states that com-
Resuscitation and Initial Assessment
Airway, Breathing, and Circulation
The prehospital provider must consider the airway needs
of patients while assessing for a potential spinal injury
that requires supine spinal immobilization. The presence of a cervical spine injury should be considered in
any trauma patient presenting with altered mental status, and manual in-line cervical stabilization should be
maintained during all emergency airway interventions.
Though oral tracheal intubation, nasal tracheal
intubation, cricothyrotomy, and transtracheal jet ventilation (TTJV) all have a similar low risk of cervical
spine injury if performed correctly, all methods cause
some degree of cervical motion. No single intubation
method conveys a greater significant risk to the unstable cervical spine if done appropriately.15,16
Primary and Secondary Survey
After evaluation and stabilization of life-threatening
abnormalities, the remainder of the patient evaluation
should focus on identifying focal neurologic deficits.
Trauma patients who are found to have life-threatening
injuries, are unstable, or are determined to have “loadand-go” conditions should have spinal immobilization
performed in a rapid fashion and transport should be
initiated.
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plete immobilization is indicated in trauma patients
with any one of these clinical criteria: altered mental
status, evidence of intoxication, a distracting painful
injury (e.g., long-bone extremity fractures), neurologic deficits, or midline spinal tenderness.
If a spinal injury is suspected based on the
provider’s spine injury assessment, care should be
taken to maintain vertebral alignment from the time
of initial evaluation to transfer to definitive care.
Although the provider is always advised to follow local protocols, it is important for the medical
director to understand that there is no definitive
evidence that spinal immobilization itself has any
positive effect on spinal-cord-injuredpatients.26
Despite a lack of efficacy evidence, spine immobilization is considered appropriate treatment for
patients with a positive spine injury assessment.
In appropriate patients, spine immobilization
consists of a rigid full-body length backboard, rigid
cervical collar, and sandbags or head blocks with
tape and/or straps across the forehead and the rigid
collar. The patient should be securely strapped to the
backboard, allowing little to no vertical or horizontal movement. In patients in whose injuries preclude
standard body and limb immobilization (e.g., femur
fracture with dislocation or foreign body in vertebral
column), reasonable attempts should be made to limit
spinal column movement and maintain alignment.
Injury-Specific Assessment
and Treatment
Stratified Assessment and Treatment
The initial evaluation and stabilization of patients
suffering a traumatic neck or back injury can be performed by basic providers, with ALS dispatched if the
situation requires ALS skills. Prehospital personnel
of any level must be aware of the potential for airway
compromise in those with cervical spine injuries.
A clear record must be kept of the initial neurologic
examination with special emphasis on any changes occurring during the assessment and transport. This is especially important in the pediatric population, who may
have transient deficits not evident on arrival to the ED.
Regional Variations
There are a number of prehospital triage tools that have
been developed to determine hospital destinations.
Though improved outcomes have been demonstrated
in patients who receive care in Level I trauma centers,27
there is a paucity of data on the outcomes of patients
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SECTION B
at trauma centers designated as “spine centers.” Opinions regarding both operative and nonoperative management of spine trauma among neurosurgeons and
orthopedic surgeons vary significantly, and there is no
demonstrated benefit of one specialist over another.
Emphasis is placed on the need for an experienced,
multidisciplinary approach to patient management.28
The field triage decision guidelines from the
American College of Surgeons Committee on Trauma
are based on the presence of hemodynamic instability, specific anatomic injuries, mechanism of injury,
and patient comorbidities.29 Although there has been
no benefit demonstrated when comparing helicopter versus ground transport of spinal patients, or air
travel in spinal patients,30 the physical distance to a
trauma center does complicate prehospital triage.
Rapid delivery of the trauma patient with suspected
spinal cord injury to a facility that can provide optimal care remains the primary principle.31
Public Health, Social, and Medical
Legal Issues
Social Issues
Overall treatment and compensation costs for patients
with traumatic neck, back, and spine injuries are estimated at $50 billion annually, placing a significant
burden on the healthcare system. In the United States,
over $5 billion is spent annually on the evaluation and
management of patients with traumatic injuries; there is
an estimated cost each year of $200,000 to $2 million
to support a patient with a spinal cord injury over the
course of his or her lifetime.32,33 Prevention of the injury
itself is vital.
Medicolegal Issues
Missed spinal cord injuries are devastating to the
patient as well as the provider. Although fear of lawsuits and defensive medicine should not necessarily determine clinical care, it is a sobering reality
that the average monetary award to a patient with a
missed cervical spine injury is $2.9 million.34 Application of a well-designed spine assessment protocol eliminates the need for selected patients to require full body immobilization. However, protocols
rely on meticulous examination and good judgment.
Should the provider have any concerns in regard to
the presence of a spinal cord injury, he or she should
err on the side of immobilization. Good documentation is always essential in patients with the potential
for high risk injury.
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CONTROVERSIES
AND FUTURE RESEARCH
Spine Immobilization in the Trauma
Patient
The question of whether spine immobilization actually
provides benefit to trauma patients is an area of great
debate. Immobilization causes back and head pain, often muddying the clinical examination and increasing
the number of radiographs required to clear the spine
in the ED.35 It also can restrict respiratory efforts, and if
used to aggressively can actually cause injury.36 Studies have questioned whether there is any measurable
improvement in outcome with spinal immobilization,37
while noting that complete spinal immobilization on
a rigid spine board is not without potential consequences and complications.38, 39 Some countries have
established treatment policy based on the lack of demonstrated efficacy of spinal immobilization.40 Further
research is needed to more fully examine the benefits
of spine immobilization.
Helmet Removal
Prehospital providers must be cautious when evaluating the unconscious helmeted patient, managing
him or her as if a vertebral or cord injury exists.
Patient movement should be avoided unless critical to maintain airway, breathing, or circulation.
Although routine removal is controversial, current
Prehospital Trauma Life Support (PHTLS) management protocols advocate complete helmet removal
rather than facemask removal alone by EMS providers41 In contrast, the National Athletic Trainer’s
Association (NATA) guidelines on the care of spine
injuries recommend immobilization of the patient
with all equipment left in place. Careful helmet removal is acceptable, if after a “reasonable” period
of time, the face mask cannot be removed or if the
design of the helmet and chin strap does not allow
for adequate airway management or prevents immobilization for transport.42 There is currently no
clear evidence in favor of EMS helmet removal versus immobilization with equipment in place. Leaving football, lacrosse and ice hockey equipment in
place for transport may be desirable in that the helmet plus shoulder pads allow for good spinal immobilization. Please note that whenever the football
helmet is removed, the shoulder pads must be removed at the same time.43 The helmet and shoulder
pads should remain in place during transport unless
specific indications require their removal, in which
case a specific protocol should be strictly followed.
EMS medical directors should work within the local
community to establish appropriate local treatment
protocols.
Steroid Usage in Spinal Shock
and Spinal Cord Injury
Although initial studies suggested that administration
of high dose methylprednisolone limited neurologic
damage secondary to acute spinal cord injuries,44
subsequent work has demonstrated significant morbidity without clear benefits.45,46 NAEMSP currently
recommends against the routine use of prehospital
steroids.47 and the literature has yet to demonstrate a
clear benefit to field administration.48
Paramedic Transcutaneous Electrical
Nerve Stimulation
In a single study, patients with pain from back injuries
had statistically better pain relief when a paramedic
placed a transcutaneous electrical nerve stimulation
(TENS) unit.49 It unclear what, if any, long-term benefits are provided from this treatment, but this may be
an area of potential further study.
Hydraulic and Bariatric Stretchers
Mechanized stair chairs and powered cots have
had a positive impact on both prehospital providers and patients. There is a reduced risk of injury
for both EMS responders and patients by eliminating many of the high-injury actions (i.e., lifting
cot from ground to ambulance). The benefits are
significant, including economic (fewer workman’s
compensation claims and days missed due to injury), increased morale, and favorable public relations through promoting greater patient comfort
and safety.
Pain Management
Treatment protocols should be written in a way to allow the provider to apply good judgment in use of
prehospital pain management. Established guidelines
with either indirect medical oversight or DMO are
beneficial for alleviating pain in both nontraumatic
and traumatic conditions.
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SUMMARY
Nontraumatic and traumatic neck and back pain have
significant financial and medical impacts on providers,
patients, and the healthcare system. Recognition of
potentially lethal conditions masquerading as benign
musculoskeletal pain is essential. Medical directors
must emphasize basic assessment and management
principles for all levels of providers, understanding
that there is controversy as to the best assessment tool
and treatment for patients with the potential for spine
injury. Prehospital management guidelines, supported
by medical oversight, are essential to provide the highest quality of care to patients.
CL I NI C A L VI G NE T T E
“Base Hospital, this is Medic 46 transporting a
19-year-old male involved in a motor vehicle crash.
He was the restrained driver of an older model compact that hit a tree head-on at low speed. There was
no air bag in the car. The patient was ambulatory at
the scene and did not lose consciousness, but he is
complaining of head and bilateral knee pain that is
a ‘4’ out of ‘10’ in severity. He appears comfortable,
with the only obvious injuries being superficial abrasions and bruising to both knees, and no cervical
or vertebral tenderness or step-offs; he is neurovascularly intact. Vitals are: blood pressure of 140/92,
heart rate 84 and regular, and an O2 saturation of
98% on room air. The patient has a smell of alcohol on his breath, although he is alert and oriented
times three with a Glasgow Coma Scale score of
15. We have initiated an IV which is hep-locked and
placed a nasal cannula and have administered 5 mg
of morphine per pain protocol. We have instituted
our spinal clearance protocol and are transporting
the patient in a position of comfort. Our estimated
time of arrival to your facility is 5 minutes. Do you
have any questions for us?”
How Would You Proceed?
Neck and back pain is very common in patients involved in MVCs. In the past, mechanism of injury
dictated the need for spinal immobilization. Current guidelines require adults to have a clear mental
status, absence of distracting injuries, and a physical examination without focal neurologic findings
before field personnel can consider omitting spine
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SECTION B
immobilization. This patient had the smell of alcohol on his breath, but he was alert, oriented, and
appropriate indicating that a reliable examination
could be performed. He did not have what the prehospital providers considered to be distracting injuries, and therefore may not require spinal immobilization. Mechanism of njury was noted, considered,
but not used as the sole decision-making criteria for
immobilization. Always know your local protocols
for selective spine immobilization.
Although the majority of acute conditions causing neck and back pain are related to trauma, the
prehospital provider needs to always consider the
medical causes of acute pain, (e.g., a ruptured aortic
aneurysm from either chronic hypertension or acute
trauma). As the DMO physician in this case, you
would be reassured by both the history and physical
examination including vital signs and GCS provided
by the prehospital providers. In many cases of neck
and back injuries, the prehospital service may not
provide any interventions other than supportive care
and transport. In cases of neurovascular compromise, or when there is a significant distracting injury,
the prehospital providers may have to provide a more
detailed physical examination or management.
Providing IV access but not necessarily a fluid bolus is reasonable in this case because the patient has
vital signs within a normal range. Although the exact
diagnosis is not often made in the prehospital arena,
prehospital triage of oriented patients presenting
with neck and back pain is very reliable as to the presence of a critical versus a minor illness or injury.
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Trauma and Environmental Incident Types
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